It is the policy of Community Health Development, Inc. (“CHDI” or “the Agency”) to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, genetic information, physical or mental disability of an otherwise qualified individual, or membership or application for membership in a uniform service, or other characteristic protected under applicable law. In accordance with requirements of the Americans with Disabilities Act, it is our policy to provide reasonable accommodation upon request during the application process to eligible applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we comply fully with applicable federal and state employment laws and the information requested on this application will only be used for purposes consistent with those laws

If yes, provide complete details on a separate sheet, including the offense(s); date(s) and places(s) of conviction, plea or deferred adjudication, and incarceration, if any; and disposition, including any suspended sentence, fine, probation, or similar disposition. Include any arrest(s) or indictment(s) for which you are out on bail or your own recognizance pending trial or other disposition. You are not required to disclose sealed or expunged records of conviction or arrest. Conviction of, plea to, or deferred adjudication for, a crime is not an automatic bar to employment. All relevant circumstances, such as how long ago the conviction or plea occurred, the crime involved, and efforts at rehabilitation will be considered in relation to specific job requirements. Use additional pages, if necessary.

(Describe any educational degrees, skills, training or experience you believe are relevant to the job applied)

SKILLS

Community Health Development, Inc. is an equal opportunity employer. CHDI does not discriminate in employment on account of race, color, religion, sex, national origin, citizenship status, age, genetic information, physical or mental disability of an otherwise qualified individual, or membership or application for membership in a uniform service, or other characteristic protected under applicable law. DO NOT APPLY IF NOT DRUG-FREE. I understand that CHDI may require as a condition of employment that I submit to a screen for illegal drug use, after it has made an offer of employment and before the commencement of any job duties. I consent to any such drug testing, and request that the laboratory disclose my results to CHDI. In addition, if hired, I further consent to drug testing at any other time deemed appropriate by CHDI in accordance with applicable law. I understand that CHDI will keep the results of any such drug tests confidential. I acknowledge and agree that any offer of employment is conditioned on the results of the drug testing, in accordance with applicable law. In addition, I acknowledge and agree that any offer of employment I may receive from CHDI is contingent on my submission of documentation that establishes my identity and verifies my legal right to work in the United States, as well as on my successful completion of a pre-employment background check. I authorize CHDI (or its agents), to evaluate me for employment purposes and to verify any information furnished by me during the hiring process, to contact all law enforcement agencies and any or all of my previous employers, references, and educational institutions, and otherwise to fully investigate my suitability for employment, character, general reputation, personal characteristics, mode of living, work habits, skills, or abilities, including contacting a credit bureau, credit agency, or other consumer reporting agency of its choice. I understand that the results of any such investigation may be disclosed to CHDI personnel involved in the employment decision, and I consent to the disclosure of any such information to CHDI by those entities and individuals. In connection with and in consideration of CHDI’s undertaking to review this application for employment and to consider me for hire, I release and acquit CHDI and its officers, directors, employees, and agents from all liability for any injury or damage of any nature, including LIABILITY FOR ANY INJURY OR DAMAGE RESULTING FROM NEGLIGENCE OR GROSS NEGLIGENCE that I may suffer or sustain by reason of its acquisition, use, or procurement of any such report or information. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for CHDI to hire me. If I am hired, I understand that either CHDI or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of CHDI has the authority to make any assurance to the contrary. I attest with my signature below that I have given to CHDI true and complete information on this application. No requested information has been concealed. I authorize CHDI to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal. If hired, I agree to comply with all rules, regulations, and operating procedures established by CHDI. I have read in full and understand the above statements and conditions of employment.